Healthcare Provider Details

I. General information

NPI: 1154145613
Provider Name (Legal Business Name): FABIAN HURTADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

IV. Provider business mailing address

4605 ELDER RD
BRAWLEY CA
92227-9771
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-7547
  • Fax:
Mailing address:
  • Phone: 619-867-8731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: